Strengthen Clinical and Billing Processes for Review Choice Demonstration

The Center for Medicaid and Medicare Services (CMS) Review Choice Demonstration (RCD) is a review of home health agency documentation to ensure the beneficiary meets requirements of the home health coverage criteria.

CMS has officially implemented RCD across five states: Ohio, Illinois, Texas, North Carolina, and Florida. No matter which review option is chosen, RCD will affect internal processes for all departments, particularly for the clinical and billing staff. It is crucial that organizations fully comprehend and recognize the impacts of the demonstration on the industry at large. Whether under pre-claim or post-payment review, benchmarking your compliance and refining your processes should be top of mind for RCD participants.

RCD’s three options

The RCD for home health services gives providers an initial choice of three options:

1. Full pre-claim review
2. Full post-payment review
3. Minimal post-payment review with a 25% payment reduction for all home health services

Choices 1 and 2 offer a reward for showing compliance with Medicare home health policies. Home health agencies participating in choice 1 or 2 will receive an affirmation rate every six months. If the rate is 90 percent or greater, subsequent review choices are offered a significant decrease in the claims reviewed for pre- or post-payment review. Achieving a 90 percent affirmation rate is extremely important for the future of your organizations as value-based strategies continue to evolve.

Identifying barriers in RCD preparedness

Reviewing processes in key areas of your organization can pinpoint issues that may cause problems with achieving a 90 percent affirmation rate. Below is a quick look at possible barriers home health agencies can encounter when trying to reach 90 percent.

Cash flow bottlenecks: RCD can cause an unexpected dip in cash flow. To prepare for this, agencies should assess where their current bottlenecks are. Common bottlenecks for cash flow include:

• Unsigned orders
• Missing/incomplete face-to-face documentation
• Unverified visits
• Pending discharges

EMR Preparedness: Most EMR platforms have been adapting their products for RCD, but agencies should still exercise caution. Reach out to your enrollment representatives or the IT support team to schedule trainings on updates.

Staffing: Home health agencies should be assessing if their current staffing model will be linear under RCD changes. Start asking yourself if your billing team is adequately staffed to account for this increased work. This includes assessing current processes to determine gaps in both clinical and non-clinical staffing needs.

Training your clinical and billing teams

All areas of your organization are affected by RCD and PDGM, but your clinical and billing teams will feel the most significant impact. It is important that adequate training takes place within your agency to review requirements and changes under RCD.

In Illinois, where RCD was implemented on June 1, 2019, these were the key documentation issues providers had to correct for affirmative billing:

• Therapy goals not properly documented
• Clinical form vs. narrative form for face-to-face documentation
• Missing face-to-face documentation
• Resumptions of care not documented within an order

To reduce documentation errors and billing deficiencies, these are topics that should be covered when training your clinical and billing staff for RCD:

• Intake staff: Conduct training on face-to-face (F2F) encounter requirements. Obtain all F2F encounter visit notes and confirm they contain the primary reason for care and are completed in a timely manner by a qualifying physician. At the time of referral/intake, it’s crucial to obtain as much history available for that patient for any referral.
• Clinical manager: At time of locking the OASIS, it is imperative to validate order, review of the functional OASIS questions, and frequency compliance established on the 485/Plan of care prior to sending it to the physician.
• Clinical discipline team: Establish effective interdisciplinary coordination based on evaluations and reflective with completion of the OASIS. Ensure all therapy staff members understand how to write measurable and specific goals for each patient.
• Order management: Without timely signatures, pre-claim submission timeframe will be slowed. Effectively manage order tracking by assessing staffing needs and ensure a strong process for confirming that all requirements are present at the time of admission for a timely turnaround.
• Billing staff: Understand what RCD billing requires and the importance of the unique tracking number (UTN). Develop final checks as part of pre-bill process to verify the UTN is on the claim prior to submission to prevent billing rejections.

Updated December 2021